RAND: ER Use Rises

May 21, 2013

Hospital emergency departments play a growing role in the U.S. healthcare system, accounting for a rising proportion of hospital admissions and serving increasingly as an advanced diagnostic center for primary care physicians, according to a new RAND Corp. study.

While often targeted as the most expensive place to get medical care, ERs remain an important safety net for Americans who cannot get care elsewhere and may play a role in slowing the growth of healthcare costs, according to the study.

Emergency departments are now responsible for about half of all hospital admissions in the United States, accounting for nearly all of the growth in hospital admissions experienced between 2003 and 2009.

Despite evidence that people with chronic conditions such as asthma and heart failure are visiting emergency departments more frequently, the number of hospital admissions for these conditions has remained flat. Researchers say that suggests that emergency rooms may help to prevent some avoidable hospital admissions.

“Use of hospital emergency departments is growing faster than the use of other parts of the American medical system,” said Art Kellermann, PhD, the study’s senior author and a senior researcher at RAND. “While more can be done to reduce the number of unnecessary visits to emergency rooms, our research suggests emergency rooms can play a key role in limiting growth of preventable hospital admissions.”

RAND was asked by the Emergency Medicine Action Fund, a consortium of emergency medicine physician organizations, to develop a more complete picture of how hospital emergency departments contribute to the U.S. healthcare system.

Researchers reviewed recent studies published about the use of emergency departments, analyzed federal information about emergency room use and conducted a series of interviews with primary care physicians, hospital-based doctors and emergency department physicians.

The study found that while admissions to U.S. hospitals grew more slowly than the nation’s overall population from 2003 and 2009, nearly all of the growth over the period was caused by a 17 percent increase in unscheduled admissions made from emergency departments. That growth more than offset a 10 percent drop in admission from doctors’ office and other outpatient settings.

Researchers say the findings suggest that office-based physicians are directing to emergency departments some patients they previously would have admitted to the hospital themselves.

The study also found that emergency departments increasingly support primary care providers by performing complex diagnostic workups that cannot be done in physician offices. In addition, emergency departments supplement primary care providers by handling overflow, after-hours cases and weekend demand for medical care.

These changes mean that emergency physicians now serve as the major decision maker for about half of all hospitals admissions in the United States. Hospital admissions account for most of hospital revenue and inpatient medical care accounts for 31 percent of nationwide health spending, making emergency room physicians a major nexus in influencing health care costs.

Researchers found that most people who seek care in an emergency department do so because they perceive no viable alternative, not because it was convenient. Researchers say the finding suggests that efforts to reduce non-urgent visits to emergency departments should focus on assuring timely access to primary care and less-expensive forms of care, rather than blocking access to emergency departments.

“We believe there needs to be more effort to integrate the operations of emergency departments into both inpatient and outpatient care systems,” said Kristy Gonzalez Morganti, the study’s lead author and a policy researcher at RAND.

Ways to accomplish this include greater use of interconnected health information technology, better coordination of care and case management, and more collaborative approaches to medical practice.

Researchers say widespread adoption of these and other practice innovations could generate savings by providing patients with better access to safe non-emergent care, which would minimize duplicative testing and avoid needless hospital admissions.

The report, “The Evolving Role of Emergency Departments in the United States,” can be found at http://www.rand.org. Other authors of the study are Sebastian Bauhoff, Janice C. Blanchard, Mahshid Abir, Neema Iyer, Alexandria C. Smith, Joseph V. Vesely and Edward N. Okeke.